Peaceful Healing Therapeutic Massage -- Health Insurance Questionnaire

Below is a list of questions and information you need to provide for your next visit:

  1. Company name: _______________________________________________________

    2. Billing address: _______________________________________________________

    ____________________________________________________________________

    ____________________________________________________________________

    Phone: ___________________________ Fax: ________________________________

    Email (optional): ________________________________________________________

    Contact name: __________________________________ Phone: __________________

    Claim number: ________________________ or policy/ID number: ______________________

  2. How much of the massage fee will your policy cover? (i.e. 100%, 80/20, only a discount on your session, etc.)

    3.   

  3. How long will they cover it for? (i.e. a certain number of visits or as long as the therapy is prescribed by your physician)

    4.   

  4. Do they require a doctor's prescription to be sent to them? (If so, it is your responsibility to obtain the prescription from a doctor accepted by your insurance company. If the doctor sends the prescription to the insurance company directly, please make sure you bring a copy to us or have one mailed to our office for your file.)

    5.   

  5. What information does your insurance company need from us? (Medical notes and an invoice are the standard. Some companies require your claim or identification number as well.)

    6.   

  6. Do we, Peaceful Healing, need to be listed with the company as a preferred provider before they will cover your massage therapy? If so, please provide a name and phone number for us to contact your insurance company about this. If we are not already approved by your insurance company and you do not provide this information to us when you book your appointment, you will be financially responsible for the cost of your therapy sessions. The session fees will be reimbursed to you as soon as we have received notice of approval and/or first payment from your insurance company.

  

I understand that non-payment of therapy by the insurance company--whether due to a limit on coverage being reached or the policy expiring or being cancelled--will be the responsibility of myself or my legal guardian.

X________________________________________________________ Date: ________________